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� DEPARTMENT OF COIvIIv1UNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 J U N 19 2002 PRESS
'"������ BUILDING PERMIT APPLICATION FI RM LY
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cn DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBV AFFIRM UNDER PENALTY OF PERJUHY THAT I AM E%EMP7 FROM THE CONTRAC70R5 LI� GefB(J9/CBfpOA
W CENSELAWFORTHEFOLLOWINGREASON�SEC.7031.SBUSINESSANDPROFESSIONSCADE:ANYCITYOR (n
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w TURE.PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNED w PaliO/DBCk
� STATEMENT THAT HE OR SHE IS LICENSED PURSUAN7 70 THE PROVISIONS OF THE CON7RACTORS LI- �
� CENSE LAW(CHAPTER B(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� POOUSPB
� FESSIONSCODE�ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (�J
V TION.ANYVIOLATIONOFSECTION7031.SBVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPIICANTTO Z Re-Roof
A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500�.):
Z ❑I,ASOWNEROFTHEPROPERTV,ORMVEMPIOYEESWITHWAGESASTHEIRSOLECAMPENSATION, � COffIfIlBfC18I �
WILI DO THE WORK,AND THE STRUCTUFE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70dd,BU51- J
N NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE lAW DOES NOT APPLY TO AN OWNER OF �
PROPERTV WHO BUIL�S OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
� THROUGHHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMEN7SARENOTINTENDEDOR m
w OFFEREDFORSALE.IF,HOWEVERTMEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE-
� TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF P{iOVING THAT HE OR SHE DID NOT BUILD OR
Z IMPROVE FOR THE PURPOSE OF SALE).
_ ❑I,ASOWNEROFTHEPROPEHTV,AMEXCLUSIVELVCANTRACTINGWITHLICENSEDCONTRACTORS
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� TO CANSTRUCT THE PRQIECT(SEC.7011,BUSINESS AND PROFESSIONS CODE:THE CONTPACTORS LI- V2IU8flOf1 ADJ.AREA
W CENSE UW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
� WHOCONTRACTSFORSUCHPRQIECTSWITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE
Y TORS LICENSE LAW.).
�� O I AM EXEMP7 UNDER SEC. B.6 P.C.FOR 7HIS REASON Q
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DATE OWNER U
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� LICENSED CONTRACTORS DECLARATION w
� t HEREBY AFFIRM UNDEH PENALTV OF PERIURV THA71 AM LICENSED UNDER PROVISIONS OF CHAPTER /',
d D(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AND PROFESSIONS CODE,AND Z V 1
X MY LICENSE IS IN FULL Fnpg C AND EFFEC7. /�
� UCENSE C S v � UC.NO. /y� � � �
V DATE CONTRACTOR /'7r � O.
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFIRM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECURATIONS: Z I
Z _IHAVEANDWILLMAMTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ , �
Q COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE w
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
w _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIPED BV SECTION
Q 370o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MV WO K S'CAMPENSATION INS ANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
¢ �27rD��
�j CARRIER ' _ . 4 / S_ PLAN REVIEW
� POLICY NUMBER ELECTRIC
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� (IHISSECTIONNE�NOTBEOCMPIEfEDOFTHEPERMRISFORONEHUPDREDDOLLl�HS�S100)ORLESS). PLUMBING
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Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C7 SHALL NOT EMPLOY ANY PERSON IN ANV MANNER 50 AS 70 BECAME SUBJECT TO THE
� WORKEfiS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
� SUBJECTTOTHEWORKERS'COMPENSATION VISIONSOFSECTION37000FTHEUBOR `l'""lO
� ^ E.I SH9LL OR�WITH COMPLY WITH R I s. ISSUANCE � v
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p DATE: � D APPLICANT: SMIP
� WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C
� SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(f7oo.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN ' '
� SECTION37oeOFTHELABOFCODE.INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE:
� CONSTRUCTION LENDING AGENCY PRE•ALT FEE:
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� 1 HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDING A�ENCY
FOR THE PERFORMANCE OFTHE WORN FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). .
Z
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� LENDER'S NAME ,
� LENDER'SADDRESS
w TOTAL FEES�J�, �D
� 1 CERTIFV THAT I HAVE READ THIS APP�ICATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT.
� I AGREE TO COMPLV WITH ALl GTV AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATNES OF THIS COUNTV TO ENTER UPON THE
Z A80VE�MENTIONED PROPERTV FOR INSPECTIOr+au� Es. COMMENTS I
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¢ PERMITTE (PRINT) � n D ,/�J/ II
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� SIGNATU OF PERMITTEE DATE
= RECPT.NO. PAID BY VALIDATION
~ WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENRO�File Co GREEN—A licant's Co
P PY. PY, PY, PY. PP PY
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FTGS/FORMS/STEEL ' ! � FHA RE�MTS ' �_
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ELECTRlC C�ROUND � � UNDE(� FL(a0�? DUCT ;
---- -- ---- ______- ---._ --------_ __..._
GR�UND PLUMBING __ ; UNQER FLOUR CUf�!DUIT i _____
SLAB GRADE � FIREPLACE FOUPVDATIOiV � __
TEMP POWER ; __FIREPLACE BOND BEAM_ � _____ ._.__. ____
- - -- - -- -
WATER SERVICE ' I_� I�1lD HT. 80ND_BCAM � � '
---- ___. _..._.._ __._ __..----- -----
ROOF SHEATHING ; 8 FL BOND BEAM ____ _____
FRAMIIVGNENTILIATION � FINAL BOfVD BEAM _ __ �
ROOF COVER PRE-GRADING _ , I __
ROUGH HEATING BENCHING _ i __
ROUGH ELECTRIC ROUGH GRADlNG
--- _--- --______ ___ ------
ROUGH PLUNIBING � � FINISH GRADING ______
SHOWER/TUB TEST POOL ELECTRIC
EXT. LATH/SIDING � POOL FENCING ,
- ----- --_ ----
WALL WSULATION � POOL.FINAL �'
— - -_..._ _____-----_ _�_.__._._ ____
CEILWG If�SULATION ' C7FF SITE IMPS. ;
DRYVVALL fVAILING DEDICATtONS
SEWER FINAL EiVG. i
� SEPTIC TANK � LANDSCAPE/IRRIG. �
SEEP PIT/l..L. ON SITE IMPS. -_._� —�__._._..
GAS AIR TEST FINAL ZOhlING
FINAL CONST. FIRE DEPT. FINAL
FINAL HEATING i HEALTH DEPT. FINAL _
FINAL ELECTRIC I � DEV. FEES PAfD _ _ i
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FINAL PLUMBI(VG i ENERGY �
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SEPTIC TANK SIZE
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